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•Graduating from a remediation program is done with a structured online curriculum•The program involves weekly readings followed by focused questions•It included a faculty mentor, practice exams and faculty lead review sessions•Residents scoring above the 30thpercentile completed more assignments post ABSITE

•EQIP is an innovative quality improvement project for surgical training programs.•Thirty-six surgical training programs with 1264 trainees and 1500 faculty members were included in the dataset.•The APDS has proved the concept that a highly secure database for the purpose of continuous risk-adjusted quality improvement in surgical education can be successfully deployed.•Risk-adjusted multivariable analysis suggests that increased time in a technical skills lab was associated with increased success on the ABS's Qualifying Examination, alone.•Increased time in a technical skills lab and the presence of a formal teaching curriculum were associated with increased success on both the ABS's Qualifying and Certifying Examination.•Program type may be of some consequence in predicting success on the Qualifying Examination.

IMPORTANCE: Persistently poorly controlled type 2 diabetes (PPDM) is common and causes poor outcomes. Comprehensive telehealth interventions could help address PPDM, but effectiveness is uncertain, and barriers impede use in clinical practice. OBJECTIVE: To address evidence gaps preventing use of comprehensive telehealth for PPDM by comparing a practical, comprehensive telehealth intervention to a simpler telehealth approach. DESIGN, SETTING, AND PARTICIPANTS: This active-comparator, parallel-arm, randomized clinical trial was conducted in 2 Veterans Affairs health care systems. From December 2018 to January 2020, 1128 outpatients with PPDM were assessed for eligibility and 200 were randomized; PPDM was defined as maintenance of hemoglobin A1c (HbA1c) level of 8.5% or higher for 1 year or longer despite engagement with clinic-based primary care and/or diabetes specialty care. Data analyses were preformed between March 2021 and May 2022. INTERVENTIONS: Each 12-month intervention was nurse-delivered and used only clinical staffing/resources. The comprehensive telehealth group (n = 101) received telemonitoring, self-management support, diet/activity support, medication management, and depression support. Patients assigned to the simpler intervention (n = 99) received telemonitoring and care coordination. MAIN OUTCOMES AND MEASURES: Primary (HbA1c) and secondary outcomes (diabetes distress, diabetes self-care, self-efficacy, body mass index, depression symptoms) were analyzed over 12 months using intent-to-treat linear mixed longitudinal models. Sensitivity analyses with multiple imputation and inclusion of clinical data examined the impact of missing HbA1c measurements. Adverse events and intervention costs were examined. RESULTS: The population (n = 200) had a mean (SD) age of 57.8 (8.2) years; 45 (22.5%) were women, 144 (72.0%) were of Black race, and 11 (5.5%) were of Hispanic/Latinx ethnicity. From baseline to 12 months, HbA1c change was −1.59% (10.17% to 8.58%) in the comprehensive telehealth group and −0.98% (10.17% to 9.19%) in the telemonitoring/care coordination group, for an estimated mean difference of −0.61% (95% CI, −1.12% to −0.11%; P = .02). Sensitivity analyses showed similar results. At 12 months, patients receiving comprehensive telehealth had significantly greater improvements in diabetes distress, diabetes self-care, and self-efficacy; no differences in body mass index or depression were seen. Adverse events were similar between groups. Comprehensive telehealth cost an additional $1519 per patient per year to deliver. CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that compared with telemonitoring/care coordination, comprehensive telehealth improved multiple outcomes in patients with PPDM at a reasonable additional cost. This study supports consideration of comprehensive telehealth implementation for PPDM in systems with appropriate infrastructure and may enhance the value of telehealth during the COVID-19 pandemic and beyond. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03520413

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Heterotopic ossification (HO), a complication after surgical repair of elbow fractures, can result in pain, decreased range of motion, or complete ankylosis of the joint. This updated systematic review focused on compiling incidence and prevalence rates of HO after surgical repair of various types of elbow fractures. The overall incidence of HO after surgical repair was calculated to be 28.7%, a result comparable with rates in the literature. Further analysis suggested that the odds of having HO may be less after distal humerus fractures than after proximal radius fractures, terrible triad injuries, and elbow fractures/dislocations. [Heterotopic ossification (HO), a complication after surgical repair of elbow fractures, can result in pain, decreased range of motion, or complete ankylosis of the joint. This updated systematic review focused on compiling incidence and prevalence rates of HO after surgical repair of various types of elbow fractures. The overall incidence of HO after surgical repair was calculated to be 28.7%, a result comparable with rates in the literature. Further analysis suggested that the odds of having HO may be less after distal humerus fractures than after proximal radius fractures, terrible triad injuries, and elbow fractures/dislocations. [Orthopedics. 2021;44(1):10–16.]

•Over 65% of nondesignated preliminary interns obtain categorical residency positions.•Standardized testing scores are predictive of nondesignated preliminary application success.•Program and administrative factors also affect nondesignated preliminary application success.

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IMPORTANCE: Traditionally, group medical visits (GMVs) for persons with diabetes improved glycemia by intensifying medications, which infrequently led to weight loss. Incorporating GMVs with intensive dietary change could enable weight loss and improve glycemia while decreasing medication intensity. OBJECTIVE: To examine whether a program of GMVs combined with intensive weight management (WM) is noninferior to GMVs alone for change in glycated hemoglobin (HbA1c) level at 48 weeks (prespecified margin of 0.5%) and superior to GMVs alone for hypoglycemic events, diabetes medication intensity, and weight loss. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial identified via the electronic medical record 2814 outpatients with type 2 diabetes, uncontrolled HbA1c, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 27 or higher from Veterans Affairs Medical Center clinics in Durham and Greenville, North Carolina. Between January 12, 2015, and May 30, 2017, 263 outpatients started the intervention. INTERVENTIONS: Participants randomized to the GMV group (n = 136) received counseling about diabetes-related topics with medication optimization every 4 weeks for 16 weeks, then every 8 weeks (9 visits). Participants randomized to the WM/GMV group (n = 127) received low-carbohydrate diet counseling with baseline medication reduction and subsequent medication optimization every 2 weeks for 16 weeks followed by an abbreviated GMV intervention every 8 weeks (13 visits). MAIN OUTCOMES AND MEASURES: Outcomes included HbA1c level, hypoglycemic events, diabetes medication effect score, and weight at 48 weeks analyzed using hierarchical generalized mixed models to account for clustering within group sessions. RESULTS: Among 263 participants (mean [SD] age, 60.7 [8.2] years; 235 [89.4%] men; 143 [54.4%] black), baseline HbA1c level was 9.1% (1.3%) and BMI was 35.3 (5.1). At 48 weeks, HbA1c level was improved in both study arms (8.2% in the WM/GMV arm and 8.3% in the GMV arm; mean difference, −0.1%; 95% CI, −0.5% to 0.2%; upper 95% CI, <0.5% threshold; P = .44). The WM/GMV arm had lower diabetes medication use (mean difference in medication effect score, −0.5; 95% CI, −0.6 to −0.3; P < .001) and greater weight loss (mean difference, −3.7 kg; 95% CI, −5.5 to −1.9 kg; P < .001) than did the GMV arm at 48 weeks and approximately 50% fewer hypoglycemic events (incidence rate ratio, 0.49; 95% CI, 0.27 to 0.71; P < .001) during the 48-week period. CONCLUSIONS AND RELEVANCE: In GMVs for diabetes, addition of WM using a low-carbohydrate diet was noninferior for lowering HbA1c levels compared with conventional medication management and showed advantages in other clinically important outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01973972

BACKGROUNDSuccessful diabetes care requires patient engagement and health self-management. Diabetes shared medical appointments (SMAs) are an evidence-based approach that enables peer support, diabetes group education, and medication management to improve outcomes. The purpose of this study is to learn how diabetes SMAs are being delivered in North Carolina, including the characteristics of diabetes SMAs across the state.METHODTwelve health systems in the state of North Carolina were contacted to explore clinical workflow and intervention characteristics with a member of the SMA care delivery team. Surveys were used to assess intervention characteristics and delivery.RESULTSDiabetes SMAs were offered in 10 clinics in 5 of the 12 health systems contacted with considerable heterogeneity across sites. The majority of SMAs were open cohorts (80%), offered monthly (60%) for 1.5 hours (60%). SMAs included a mean of 7.5 ± 3.4 patients with a maximum of 11.2 ± 2.7 patients. Survey data revealed barriers (cost-sharing and provider buy-in) to, and facilitators (leadership support and clinical champions) of, clinical adoption and sustained implementation.LIMITATIONSExternal validity is limited due to the small sample size and geographic clustering.CONCLUSIONThere is significant heterogeneity in the delivery and characteristics of diabetes SMAs in North Carolina with only modest uptake across the health systems. Further research to determine best practices and effectiveness in diverse, real-world clinical settings is required to inform implementation and dissemination efforts.

We assessed potential racial or ethnic differences in the degree to which veterans with pharmaceutically treated hypertension report experiences with their primary care system that are consistent with optimal chronic illness care as suggested by Wagner's Chronic Care Model (CCM).

Unstable fracture-dislocations of the elbow, and in particular the “terrible triad” injury consisting of an elbow dislocation with a fracture of the radial head and coronoid, are complex injuries that can be plagued and complicated by persistent instability. Acute and chronic instability is a difficult problem and is best managed early by avoidance and restoration of stability. A number of treatment options have been proposed to manage acute postfixation instability of the elbow joint. Traditional stabilization options include immobilization with splinting or casting, cross-articular pinning, and external fixation (hinged or static), followed by early physical therapy. However, each of these approaches can still yield persistent elbow instability. We are proposing a new technique of acute but temporary bridge plate stabilization of the elbow joint to protect the concentrically reduced elbow joint following repair of all injured structures to restore stability followed by staged removal and the delayed initiation of therapy.

Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and earlier return to normal activity. Concurrent robotic inguinal hernia repair at the time of prostatectomy has been shown to have a lower recurrence rate than open repair. Robotic surgery adds high definition visualization and articulating instruments which enhances dexterity that makes laparoscopic hernia repair more refined. A series of robotic, laparoscopic, inguinal hernia repairs by a single surgeon with an extensive laparoscopic hernia experience at a single institution was undertaken to determine the role of robotic laparoscopic inguinal hernia repair in minimally invasive surgery. Five hundred forty-two laparoscopic inguinal hernia operations were performed from April 2012 through December 2015. There were 154 cases of robotic transabdominal pre-peritoneal procedures done during that time. Hospital records and follow-up care were pro-spectively reviewed and data collected for age, sex, American Society of Anesthesia class, and operative time. Follow-up was done at 2, 8, and 16 weeks after surgery. All patients consented for the study. Ninety percent of the patients were male. Age averaged 57.04 years with a range of 21 to 85 years. American Society of Anesthesia averaged 2.01 with comorbidities of hypertension, hypercholesterolemia, and gastroesophageal reflux disease being the most common. Body mass index was between 19 and 31.6, averaging 24.34. Twenty-five patients (16%) had an umbilical hernia repair done concomitantly. Operating room time ranged from 25 to 140 minutes with an average of 63.6 minutes decreased as experience increased. One patient with a large, left scrotal hernia was converted to open; one patient developed perforated sigmoid diverticulitis seven days postop and case #5 recurred indirectly after a direct hernia repair. Four patients required prolonged postoperative Foley catheterization. Robotic inguinal hernia repair is safe and effective. Operating room time was longer than standard laparoscopic herniorrhaphy but decreased with experience. A single-port platform may have use in patients with umbilical hernias, 16 per cent, and will need to be studied.

Surgery residents are required to achieve performance milestones to advance in their residency. Level-specific, technical performance norms that could be used as milestones, however, do not currently exist. Our aim was to develop level-specific, technical performance norms for general surgery residents on select simulated tasks across multiple institutions. An IRB-approved, prospective, multi-institutional collaborative study with voluntary participation of residents was undertaken at the start of the 2011–2012 academic year. General surgery residents (PGY I–V) from seven institutions were tested on three laparoscopic and five open simulated surgical tasks, and their performance was assessed based on task time and errors. Means and standard deviations of performance for each resident level were calculated and compared. Residents with performance 1 standard deviation below the mean were considered outliers. A total of 147 residents were evaluated. Mean resident age was 28 ± 3 years; 42 % were female; and they had attended 74 different medical schools. Senior residents (PGY III–V) had more clinical and simulator experience than junior residents (PGY I–II) (p< 0.001). Resident performance scores progressively increased in all tasks reaching a plateau at a lower PGY level for open tasks. Depending on the task, 0–18 % of residents were outliers. When surveyed, 66 % of residents agreed that national performance norms for residents should exist. Performance norms were established for select tasks in a representative sample of US surgery residents. Such performance norms allow a more informed assessment of resident skill through comparison to national data and enable the identification of outliers who may benefit from additional training.

Hypertension self-management has been shown to improve systolic blood pressure (BP) control, but longer-term economic and clinical impacts are unknown. The purpose of this article is to examine clinical and economic outcomes 18 months after completion of a hypertension self-management trial.

Obesity is associated with a higher risk of remote organ failure after shock and trauma. The mechanism(s) is poorly understood. Polymorphonuclear cell (PMN) inflammatory responses are important in the pathogenesis of organ injury following shock. Morbid obesity is a low-grade inflammatory state associated with proinflammatory mediator production from adipose tissue. We hypothesized that adipose tissue may modulate PMN inflammatory potential and is dependent on the magnitude of the injury-related stress response. This was studied in an in vitro model.

Taking the Conceptual Plan of Anyang Eastern Town as the subject, the article presents key issues and learnings from the exercise carried out. The authors point out that sustainable development as a concept and practice is little known at the provincial level in China. Policy initiatives and regulations from the central government are aimed at broad environmental needs; their integration with urban planning has not yet taken place. This plan for the city of Anyang is innovative in that it is guided by principles such as the (i) creation of a city, capable of establishing livable neighbourhoods with an increased landscaped urbanism, (ii) development of an identity that connects the local cultural heritage with the new development, and (iii) provision of several typologies capable of defining neighbourhoods and accommodating varying densities, house typologies, commercial services and connectivity to the urban green space.

Since the Industrial Revolution, the concentration of greenhouse gases (GHG), primarily carbon dioxide (CO2), has put increasing pressure on the atmosphere's ability to absorb them. China is the fastest growing major economy in the world, and is following a process of rapid industrialization. This process, however, contributes dramatically to global warming through major CO2emissions. The widespread provision of electricity through coal-fired power plants is just one contributor, but industrial structures, transportation systems, and the construction of large superblock residential towers also play major roles. The large cities and industrialized provinces of China emit the most CO2, a fact that requires serious attention. However, stemming this trend elsewhere in China would provide a greater opportunity for success in reducing overall CO2emissions in the country. Consequently, the question this paper addresses is what policies can be adopted to reduce CO2emissions in provinces in China where development is still in its early stages, while maintaining economic growth. Jiangxi is a province that has historically been a major agricultural area. In recent years, however, because of the economic development policies of the Chinese central government, the province's rich mineral deposits, favorable location, and convenient transportation system are attracting more investments and projects for development (Statistical Bureau of Jiangxi, 2010). Jiangxi, then, provides an excellent case study because the province, although developing quickly, might still produce less CO2if proper growth policies and actions are implemented. According to the results of this research, CO2emissions would indeed decline in Jiangxi if the province would adopt new technology for electricity generation and increase the GDP role of the service sector.

ABSTRACT: Individuals diagnosed with impaired glucose tolerance (i.e., prediabetes) are at increased risk for developing diabetes. We proposed a clinical trial with a novel adaptive randomization designed to examine the impact of a home-based physical activity (PA) counseling intervention on metabolic risk in prediabetic elders. This manuscript details the lessons learned relative to recruitment, study design, and implementation of a 12-month randomized controlled PA counseling trial. A detailed discussion on how we responded to unforeseen challenges is provided. A total of 302 older patients with prediabetes were randomly assigned to either PA counseling or usual care. A novel adaptive design that reallocated counseling intensity based on self-report of adherence to PA was initiated but revised when rates of non-response were lower than projected. This study presents baseline participant characteristics and discusses unwelcome adaptations to a highly innovative study design to increase PA and enhance glucose metabolism when the best-laid plans went awry.

Individuals diagnosed with impaired glucose tolerance (i.e., prediabetes) are at increased risk for developing diabetes. We proposed a clinical trial with a novel adaptive randomization designed to examine the impact of a home-based physical activity (PA) counseling intervention on metabolic risk in prediabetic elders. This manuscript details the lessons learned relative to recruitment, study design, and implementation of a 12-month randomized controlled PA counseling trial. A detailed discussion on how we responded to unforeseen challenges is provided. A total of 302 older patients with prediabetes were randomly assigned to either PA counseling or usual care. A novel adaptive design that reallocated counseling intensity based on self-report of adherence to PA was initiated but revised when rates of non-response were lower than projected. This study presents baseline participant characteristics and discusses unwelcome adaptations to a highly innovative study design to increase PA and enhance glucose metabolism when the best-laid plans went awry.

The true recurrence rate after umbilical hernia repair in not known. After simple closure, the reported rate of recurrence in the literature is as high as 54 per cent. With synthetic mesh repair, the recurrence rates are lowered to less than 10 per cent. However, synthetic mesh is associated with complications such as enterocutaneous fistula and mesh infections. This preliminary study looks at the safety and effectiveness of biologic extracellular matrix mesh reinforcement in the repair of umbilical hernias. We retrospectively reviewed all patients who underwent repair of an umbilical hernia defect (2-3 cm) with primary approximation of the margins and reinforced using a biologic mesh placed beneath the umbilical fascia from 2007 to 2009. Demographic data were collected. Patients were followed prospectively at 2 weeks, 8 weeks, 6 months, and 1 year. Data were reviewed for postoperative complications, hernia recurrence, and patient satisfaction. During the study period, 16 patients completed the 1 year follow-up. There were 10 men and six women. Ages ranged from 28 to 75 years with a mean age of 47.6 years. The hernias were 2 to 3 cm in size. Complications were minimal. Overall patient satisfaction with the procedure was high. There were no mesh infections. During a mean follow-up of 12 months, only one patient had recurrent hernia (6%). This preliminary evaluation shows promise for an alternative treatment of umbilical hernias using biologic extracellular matrix mesh added as an underlay to reinforce a primary closure. The biologic mesh has a low incidence of infection and complications and results in high patient satisfaction. This preliminary study begs for a randomized, prospective evaluation with long-term follow-up.

A comparison between soft prolene mesh and bioactive extracellular matrix prosthetic mesh fixed and secured with fibrin glue was studied.

Some physicians feel gastric injury is not a significant contributing factor to the adverse outcome of trauma patients, but rather a marker of epigastric injury. We hypothesized the addition of a gastric injury to multiple injured trauma patients would increase infection rate. We conducted a retrospective study comparing 450 consecutive patients with full-thickness gastric injury with 983 patients without gastric injury during the same time period. Infection rate in patients with gastric injury was 44 per cent (200 of 455) and significantly higher than 36 per cent (357 of 983) seen without gastric injury (P = 0.006). Logistic regression revealed gastric injury was an independent risk factor for infection controlling for age, Injury Severity Scale, gender, mechanism of injury, shock, and associated injuries (P = 0.047). Requiring a transfusion, Injury Severity Scale, colon injury, age, pancreas injury, and emergency department shock were also independent risk factors for developing an infection. The addition of a gastric injury to a trauma patient appears to increase the risk for infection.

Abstract: Background: In recent years there has been a rapid increase in the use of proton pump inhibitors. Our institution has recently had several shortages of IV pantoprazole, each lasting 7–10 days. The purpose of our study was to evaluate in-patient usage of IV pantoprazole. We hypothesized that hospitalized patients with upper gastrointestinal bleeding (GIB) or risk for stress ulcers inappropriately received IV pantoprazole based on current literature. Methods: This was a retrospective study of 165 consecutive in-patients identified as receiving pantoprazole from December 2004 to March 2005. Only patients receiving IV pantoprazole were included (n = 78). Data collected included demographics, indication and dosing of pantoprazole, admitting team (surgery vs. medicine), and risk factors for stress ulcers. Results: Our study population had a mean age of 54 ± 17 years and 62% were male. Overall, 45% (35/78) of patients receiving IV pantoprazole had an appropriate indication, and 19% (15/78) received the correct dose. Of the 78 patients, 43 (55%) were treated with pantoprazole for stress ulcer prophylaxis (SUP), and 35 (45%) patients were treated for GIB. We found that none of the 43 patients treated for SUP had an appropriate indication for pantoprazole, but all of the patients with GIB (35) had an appropriate indication. Of the 35 patients treated for GIB with pantoprazole, only 40% (14/35) received the correct dose. In all cases of incorrect dosing, the patients were underdosed. Conclusions: Pantoprazole is not being prescribed appropriately for stress ulcer prophylaxis in our patient population. Even in patients appropriately receiving pantoprazole the majority were prescribed an incorrect dose. Appropriate indications and dosing of pantoprazole could eliminate the shortages seen at our institution.

Adequate nutritional support after thermal burn injury is essential for achieving successful patient outcomes. Dysphagia is common in burn patients. Our objective was to analyze hospitalized burn patients referred to speech pathology for swallowing evaluation. A retrospective study of burn patients admitted to our center and evaluated by speech pathology from December 2001 through July 2006 was performed. Of the 16 patients, 5 (31%) had a normal bedside swallow examination, did not undergo a modified barium swallow study (MBSS), and were excluded. Six (55%) of the 11 included patients were men. The average age was 44 ± 18 years. All 11 patients had a thermal burn with an average total body surface area burn of 36% ± 16%. Facial burns were present in 91% (10 of 11) of the patients, and inhalation injury was confirmed by bronchoscopy in 55% (6 of 11) of the patients. The average length of stay was 84 ± 45 days. Of the 11 abnormal bedside assessments performed, 10 (91%) were associated with an abnormal MBSS. One patient had evidence of oral dysphagia only and one patient had evidence of pharyngeal dysphagia only. Six patients had oral and pharyngeal dysphagia, and two patients had pharyngeal and esophageal dysphagia. One tracheal-esophageal fistula was identified. A bedside assessment of swallowing performed by a speech pathologist is predictive of an abnormal modified barium swallow in burn patients. Burn patients with facial burns, inhalation injury, pneumonia, and a prolonged ICU stay are at increased risk for dysphagia. Prospective studies are necessary to determine in which patients an MBSS adds additional relevant clinical information.

Patients who continue to smoke while on home oxygen therapy endanger themselves, family members, neighbors, and firefighters and create an expense to society for their medical care. This phenomenon was studied in our burn center. Fourteen patients were identified prospectively during the last 2 years. All were smoking while on nasal oxygen. The 14 patients (10 males) were 45 to 87 years of age. All suffered facial burns. Only one patient had a significant burn (30% TBSA, 20% 3rd degree), but all suffered from an exacerbation of chronic obstructive pulmonary disease. Two patients gave a history of stage IV lung cancer and four patients had newly found squamous cell cancer seen on bronchoscopy. All six patients with lung cancer and one with severe chronic obstructive pulmonary disease died. Of the seven survivors, only one patient quit smoking. Total charges were $2,861,526 and total costs were $938,311. All patients had Medicare or Medicaid on admission. Hospital loss ($432,561) was incurred in those patients admitted more than 4 days whereas a profit ($33,285) was realized in patients admitted less than 4 days. These deaths and financial loss could be reduced by better testing and more precise guidelines as to which patients can safely receive home oxygen. Patients can have their saliva tested for the nicotine breakdown product of cotinine; the test takes 10 minutes. The American Burn Association, in conjunction with the American College of Chest Physicians, should address this issue and develop guidelines for physicians who order home oxygen therapy and for state departments of public health who should regulate the companies that deliver home oxygen.

Lower gastrointestinal bleeding (LGIB) continues to be a problem for physicians. Acute LGIB is defined as bleeding that emanates from a source distal to the ligament of Treitz. Although 80% of all LGIB will stop spontaneously, the identification of the bleeding source remains challenging and rebleeding can occur in 25% of cases. Some patients with severe hematochezia require urgent attention to minimize further bleeding and complications. This article reviews the causes, diagnostic methods, and endoscopic treatment of LGIB.

We sought to evaluate the incidence, morbidity, and mortality of pneumonia among inhalation injury patients requiring admission to our burn unit. We undertook a retrospective study of 228 consecutive patients with inhalation injury who were admitted to the burn unit of a level one trauma center between 2001 and 2004. Of the remaining 117 patients with inhalation injury and requiring hospitalization for at least 48 hours, 32 (27%) developed pneumonia. The average patient with inhalation injury and pneumonia developed their infiltrate on day 6 ± 5 days and required 3 ± 4 burn operations. There was no difference seen in age, sex, or carboxyhemoglobin level between inhalation injury patients with and without pneumonia (P> .05). The inhalation injury patients that had an associated TBSA burn of at least 20% had a 60% (12/20) pneumonia rate, which was significantly higher then the 21% (20/97) pneumonia rate observed in patients with an association burn less then 20%. The overall mortality of patients with inhalation injury and pneumonia was 19% (6/32), double the mortality rate of 9% (8/85) found in patients with inhalation injury and no pneumonia. The average length of stay of inhalation injury patients with pneumonia was significantly longer (47 ± 44 days) then inhalation injury patients without pneumonia (26 ± 54 days; P< .05). The presence of pneumonia among inhalation injury patients significantly increased length of stay and doubled mortality rates. Admission carboxyhemoglobin levels, age, and sex had no relationship to the development of pneumonia. An increase in TBSA burn was associated with a higher pneumonia rate.

It is generally accepted that patients with a systolic blood pressure (SBP) <90 mmHg are in "shock" and have a worse prognosis than patients with a higher SBP. Our objective was to determine if patients with a SBP of 90-109 mmHg have a worse outcome than patients with a higher SBP following trauma. Patients with gastric, small bowel, and/or diaphragm injuries were identified retrospectively through the trauma database from 1980-2003. All 2071 patients underwent emergent laparotomy at an urban, level one trauma center. The mortality rate of patients with a SBP of 90-109 mmHg in the ED or OR was 5% (17/354) and significantly higher than the 1% (12/1020) mortality seen in patients with a SBP of 110 mmHg or greater (P< 0.001). The average length of stay of patients with a SBP of 90-109 mmHg was 15 ± 14 days and was significantly longer than the 11 ± 11 days seen in patients with a higher SBP. If the SBP was 90-109 mmHg, the infection rate was 39% (131/340), and this was significantly higher than the 22% (219/1016) infection rate seen in patients with higher SBP (P< 0.001). Trauma patients with a systolic blood pressure of 109 mmHg or below are at increased risk for morbidity and mortality following trauma. Patients with a systolic blood pressure of 90-109 mmHg following trauma should be considered as a special group requiring aggressive resuscitation and surgery. Early operative control of hemorrhage in these patients can reduce mortality and infection.

Vessels of the pulmonary microvasculature are composed of two cell types: endothelial cells and pericytes. Pericytes are crucial to the development of capillary leak and pulmonary edema seen in acute respiratory distress syndrome (ARDS). Pericytes express toll-like receptor-4, and is upregulated in response to lipopolysaccharide (LPS). The objective of this study was to evaluate secretory cytokine production by rat microvascular pericytes. It is our hypothesis that pericytes secrete interleukin (IL)-1B, IL-6, and tumor necrosis factor (TNF)-A in response to LPS.